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A Biomechanical Evaluation of an

Anatomical Coracoclavicular
Ligament Reconstruction
Augustus D. Mazzocca,* MD, Stephen A. Santangelo, Sean T. Johnson, MD,
Clifford G. Rios, MD, Mark L. Dumonski, MD, and Robert A. Arciero, MD
From the University of Connecticut Health Center, Farmington, Connecticut

Background: Despite numerous surgical techniques described, there have been few studies evaluating the biomechanical
performance of acromioclavicular joint reconstructions.
Purpose: To compare a newly developed anatomical coracoclavicular ligament reconstruction with a modified Weaver-Dunn
procedure and a recently described arthroscopic method using ultrastrong nonabsorbable suture material.
Study Design: Controlled laboratory study.
Methods: Forty-two fresh-frozen cadaveric shoulders (72.8 13.4 years) were randomly assigned to 3 groups: arthroscopic
reconstruction, anatomical coracoclavicular reconstruction, and a modified Weaver-Dunn procedure. Bone mineral density was
obtained on all specimens. Specimens were tested to 70 N in 3 directions, anterior, posterior, and superior, comparing the intact
to the reconstructed states. Superior cyclic loading at 70 N for 3000 cycles was then performed at a rate of 1 Hz, followed by
a load to failure test (120 mm/min) to simulate physiologic states at the acromioclavicular joint.
Results: In comparison to the intact state, the modified Weaver-Dunn procedure had significantly (P < .05) greater laxity than
the anatomical coracoclavicular reconstruction or the arthroscopic reconstruction. There were no significant differences in bone
mineral density (g/cm2), load to failure, superior migration over 3000 cycles, or superior displacement. The anatomical coracoclavicular reconstruction had significantly less (P < .05) anterior and posterior translation than the modified Weaver-Dunn procedure. The arthroscopic reconstruction yielded significantly less anterior displacement (P < .05) than the modified Weaver-Dunn
procedure.
Conclusion: The anatomical coracoclavicular reconstruction has less anterior and posterior translation and more closely
approximates the intact state, restoring function of the acromioclavicular and coracoclavicular ligaments.
Clinical Relevance: A more anatomical reconstruction using a free tendon graft of both the trapezoid and conoid ligaments may
provide a stronger, permanent biologic solution for dislocation of the acromioclavicular joint. This reconstruction may minimize
recurrent subluxation and residual pain and permit earlier rehabilitation.
Keywords: shoulder; acromioclavicular joint; biomechanics; surgery; anatomical reconstruction

these injuries can be classified with increasing severity as


type I through type VI.20 Typically, the first-degree and
second-degree sprains of the acromioclavicular joint, otherwise known as type I or type II injuries, are treated nonoperatively, with the majority of patients returning to preinjury
status.6-8,11,18 Although the treatment of type III dislocations
remains controversial, high-grade injuries, typically types IV,
V, and VI, with more than 100% displacement in a posterior
and/or inferior direction, are typically treated surgically.
The literature is replete with surgical techniques to
address complete acromioclavicular dislocations, including
primary repair of the coracoclavicular ligaments, augmentation with autogenous tissue (coracoacromial ligament),

Acromioclavicular joint separation represents one of the


most common shoulder injuries seen in general orthopaedic
practice. The most common mechanism of this injury is a fall
with a direct force to the lateral aspect of the shoulder and
with the arm in an abducted position. Depending on the
magnitude of injury to the acromioclavicular joint capsule
and ligaments as well as to the coracoclavicular ligaments,
*Address correspondence to Augustus D. Mazzocca, MD, 10 Talcott
Notch Road, Farmington, CT 06034-4037 (e-mail: admazzocca@
yahoo.com).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 2
DOI: 10.1177/0363546505281795
2006 American Orthopaedic Society for Sports Medicine

236

References 1, 2, 4, 5, 14, 16, 20-22, 24, 26, 27.

Vol. 34, No. 2, 2006

Figure 1. Clavicle potted to left and secured to actuator.


augmentation with absorbable and nonabsorbable sutures
as well as with prosthetic material, and coracoclavicular stabilization with metallic screws. The Weaver-Dunn technique
using transfer of the coracoacromial ligament has been the
most popular procedure for both acute and chronic injuries.25
Several recent reports have described good results with modifications of the Weaver-Dunn technique.16,22,26 However, in
2 independent studies by Tienen et al22 and Weinstein et al,26
compromised results were observed in patients who had
residual subluxation or dislocation after surgery.
From a biomechanical perspective, the importance of the
coracoclavicular ligaments and acromioclavicular ligaments in controlling superior and horizontal translations
has been elucidated.9,10,13,15 In fact, failure to surgically
reproduce the conoid, trapezoid, and acromioclavicular ligament function with current techniques may explain the
observed incidence of recurrent instability and pain.13,15
Several authors have advocated using a separate and
potentially more robust graft source to improve surgical
results.5,18 The use of a free autograft or allograft tendon has
been further supported biomechanically.17
The purpose of this study was to evaluate the biomechanical performance of a new double-bundle, 2-tunnel anatomical reconstruction of the coracoclavicular ligaments and to
compare it with a modified Weaver-Dunn technique and
an arthroscopic coracoclavicular ligament sling technique
using an ultrastrong nonabsorbable suture material. The
hypothesis is that the anatomical coracoclavicular ligament
reconstruction will more closely restore stability of superior,
anterior, and posterior translations. Ultimately, in achieving these anatomical and biomechanical goals with a graft
source of sufficient strength, the incidence of postoperative
subluxation and dislocation as well as residual pain will
result in improved clinical outcomes.

MATERIALS AND METHODS


Forty-two fresh-frozen cadaveric shoulders were randomly
assigned to 3 groups: arthroscopic reconstruction, anatomical

References 1, 3-5, 14, 17, 19-24, 26, 27.

Anatomical Coracoclavicular Ligament Reconstruction

237

Figure 2. The modified Weaver-Dunn procedure. The distal


clavicle is resected, and the coracoacromial ligament is transferred through the intramedullary canal of the distal clavicle
and secured.

coracoclavicular reconstruction, and a modified Weaver-Dunn


procedure. A priori power analysis using a 2-mm difference
as significant established a sample size of 14 per group with
= .05 and r = 0.8. Bone density measurements were
obtained in all specimens.

Specimen Preparation
Forty-two fresh-frozen cadaveric shoulders were used in this
study (mean age, 72.8 13.4 years). Before the day of testing, each shoulder specimen was thawed overnight at room
temperature. Each shoulder was disarticulated at the glenohumeral joint, and the clavicle and scapula were dissected
free of all soft tissue except the acromioclavicular joint capsule, coracoclavicular ligaments, and coracoacromial ligament. All specimens were then evaluated for bone density
with a Lunar DPI XQ dexascan (Madison, Wis). Subsequently,
the scapula was potted with epoxy in a custom block from
the inferior angle to the edge of the glenoid. The clavicle was
also potted in a custom block mold to 5 mm medial to the
coracoid process. The specimens were then tested in a randomized 2-step process for each condition: anterior-posterior
and inferior-superior using an MTS Servohydraulic testing
system (MTS Systems Corp, Eden Prairie, Minn). Anterior
and posterior testing was accomplished by fixing the clavicle to the actuator in such a manner that the anterior direction was in line with actuation. The clavicle was first fixed
in a nonrigid fashion to allow for calibration of the load cell.
The load was zeroed, and the clavicle was rigidly attached.
The scapula was allowed to float on a fixture base while the
displacement of the actuator was adjusted to a zero load
position, thus indicating anatomical origin of the clavicle
relative to the scapula. A custom guide was used to drill a
3/8-in hole in the potting of the scapula to mate with a permanently mounted bolt on the fixture base. The specimen

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Mazzocca et al

was then bolted into the prescribed anatomical position,


ensuring reproducibility when reinstalling the specimen in
the fixture (Figure 1).

Mechanical Testing
For inferior-superior testing, the specimen was rotated
such that when the clavicle was attached to the load cell,
the scapula was in line with the actuator. With the load cell
calibrated, the same process of actuator adjustment was
made to find the defined anatomical origin, and a second
3/8-in bolt provided fixation in this orientation.
All specimens were conditioned for 10 cycles to 25 N for
anterior-posterior and inferior-superior testing to eliminate creep phenomenon. The specimens were randomly
loaded to 70 N in either the anterior-posterior or inferiorsuperior, with all ligaments of the acromioclavicular joint,
coracoacromial ligament, and coracoclavicular ligaments
intact to further eliminate creep. Net displacement values
were recorded for anterior, posterior, and superior displacements. Next, the acromioclavicular and coracoclavicular ligaments were completely sectioned. Random reconstructions
were performed with the Weaver-Dunn procedure an
arthroscopic reconstruction of the coracoclavicular ligaments using an ultrastrong nonabsorbable suture material,
or an anatomical 2-bundle coracoclavicular ligament reconstruction on each specimen.
When the specimen was reconstructed, the testing procedure for the intact state was repeated, followed by a
load-to-failure test in which the clavicle was outfitted with
a support both medial and lateral to the reconstruction to
eliminate failures of the clavicle due to an increased stress
concentration at the potting interface.

Surgical Reconstructions
Modified Weaver-Dunn Technique. Ten millimeters of the
distal clavicle were excised. Two 1.6-mm drill holes were
then made in the superior portion of the clavicle 3 mm from
the distal end, exiting into the intramedullary canal. The
coracoacromial ligament was then transected sharply from
its acromial attachment. A running locking stitch using No.
2 FiberWire (Arthrex Inc, Naples, Fla) was weaved into the
distal end. The 2 free ends of the suture were then passed
into the drill holes created in the distal clavicle through the
medullary canal. The clavicle was then reduced into an
anatomical position, and the coracoacromial ligament was
secured and tied.
Two additional 1.6-mm drill holes, placed 15 mm and
25 mm from the distal end, were created to secure an additional augmentation suture. This suture, No. 2 FiberWire
(Arthrex Inc), further secured the clavicle to the coracoid
by threading the suture around the base of the coracoid
and through the drill holes in the distal clavicle (Figure 2).
Anatomical 2-Bundle Coracoclavicular Ligament
Reconstruction. Based on a previous unpublished study
on osteological analysis of 118 clavicles, the mean length
from the end of the clavicle or acromioclavicular joint
to the most medial insertion of the coracoclavicular

The American Journal of Sports Medicine

ligaments was 46.3 mm. The distance between the trapezoid


ligament laterally and the conoid ligament medially was
21.4 mm. The anatomical centers of the attachment sites
on the undersurface of the clavicle of the trapezoid and
conoid ligaments can be carefully delineated, especially
in this particular study, after having these ligaments
freshly transected. Anatomical graft reconstruction
depends on a free graft that can be either autograft or
allograft tissue. Lee et al17 found no difference in peak
load to failure between semitendinosus, toe extensor, and
gracilis tendons for reconstruction of the coracoclavicular
ligaments in a single-tunnel loop reconstruction of the
coracoclavicular ligaments. Therefore, a semitendinosus
tendon graft is doubled over and secured with No. 2
FiberWire (Arthrex Inc) into the doubled-over portion of
the graft for a distance of approximately 2 to 2.5 cm.
Another No. 2 FiberWire suture is also weaved in a baseball-type fashion into the distal 2 tails of this graft. A
6-mm or 7-mm bone tunnel socket is then created in the
base of the coracoid (Figure 3). The depth of this coracoid
bone socket is approximately 15 to 17 mm. A biotenodesis
screwdriver is then assembled, and this device is used to
dock the doubled-over portion of the graft into the base of
the coracoid bone socket. A bioabsorbable interference
screw, 5.5 mm in diameter by 15 mm in length (Arthrex
Inc), is then placed, securing fixation of the graft in the
coracoid (Figure 4).
Bone tunnels in the distal clavicle are then created.
The tunnel for the conoid ligament is made approximately
45 mm medial from the distal end of the clavicle in the posterior one half of the clavicle in a superior-to-inferior direction. Once again, a 6-mm transosseous tunnel is created.
This same procedure is repeated to create the tunnel for
the trapezoid ligament (Figure 3). This tunnel is a more
anterior structure and is typically placed in the center
point of the clavicle, approximately 15 mm lateral to the
center of the previously placed tunnel. The acromioclavicular joint is overreduced by 2 mm. Once again, using the
biotenodesis screwdriver, a 5.5 15-mm bioabsorbable
interference screw is placed into the posterior tunnel, fixing the conoid ligament. A similarly sized screw is subsequently placed into the trapezoid ligament (Figure 5).
Arthroscopic Coracoclavicular Ligament Reconstruction.
This following reconstruction is proposed as a technique
that can be done arthroscopically but was not done arthroscopically in the study. Ten millimeters of the distal clavicle
were excised. A single guide pin was drilled through the
clavicle into the base of the coracoid process 20 mm from the
distal end. A 4-mm cannulated reamer was used to drill
through both the clavicle and the coracoid process, and a
suture passer is passed through the reamer (Figure 6A). A
fully threaded 5.5 15-mm cannulated titanium screw was
inserted through the clavicle into the inferior aspect of the
coracoid process. A second 5.5 15-mm rounded head screw
was inserted into the clavicle such that the head of the screw
was flush with the superior aspect of the clavicle (Figure
6B). A double loop of No. 5 FiberWire (Arthrex Inc) was
loaded through both cannulated screws (Figure 6C). The
clavicle was reduced, and the FiberWire was tied to itself
anterior to the coracoid (Figure 6D).

Vol. 34, No. 2, 2006

Figure 3. The anatomical coracoclavicular reconstruction


showing position of the bone tunnels relative to the distal end
of the clavicle. A 6-mm or 7-mm bone tunnel socket is then
created in the base of the coracoid.

Anatomical Coracoclavicular Ligament Reconstruction

239

Figure 5. The anatomical coracoclavicular reconstruction.


Using the biotenodesis screwdriver, a 5.5 15-mm bioabsorbable interference screw is placed into the posterior
tunnel, fixing the conoid ligament. A similarly sized screw is
subsequently placed into the trapezoid ligament.

The specimens were then returned to the MTS and conditioned for 10 cycles at 25 N in the anterior-posterior and
inferior-superior planes to eliminate creep of the graft or
suture material. The protocol for intact stability testing was
repeated, and all displacement values were recorded. The
specimen was then cycled to 70 N in the inferior-superior
plane for 3000 cycles at a rate of 1 Hz while recording cyclic
displacement to 0.1 mm. Cyclic testing was followed by a
load-to-failure tensile test at 120 mm/min in the inferiorsuperior plane, and the ultimate tensile load was recorded.
A summary of the testing sequence after reconstructions
is depicted in Figure 7.

Statistical Analysis

Figure 4. The anatomical coracoclavicular reconstruction. A, a


biotenodesis screwdriver is assembled and then used to dock
the doubled-over portion of the graft into the base of the coracoid bone socket. B, a bioabsorbable interference screw,
5.5 mm in diameter by 15 mm in length, is then placed,
securing fixation of the graft in the coracoid.

Intact-to-reconstructed displacement values were compared


using paired analysis of variance. Displacement data for each
reconstructed shoulder were then normalized to the intact
state and compared groupwise with the Tukey post hoc testing. Load-to-failure data were also analyzed with Tukey post
hoc testing.
Postreconstruction displacement was analyzed using
displacement and load-to-failure values for each reconstruction. These values were normalized to the intact state
and compared in 3 directions (anterior, posterior, and superior) using the Tukey post hoc test. A statistical significance level was set at P < .05.

RESULTS
The bone mineral density did not statistically vary among
the groups tested.

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Mazzocca et al

The American Journal of Sports Medicine

Figure 6. Arthroscopic coracoclavicular ligament reconstruction.


A, a 4-mm cannulated reamer was used to drill through both
the clavicle and coracoid process, and a suture passer is
passed through the reamer. B, a fully threaded 5.5 15-mm
cannulated titanium screw was inserted through the clavicle
into the inferior aspect of the coracoid process. A second
5.5 15-mm rounded head screw was inserted into the clavicle such that the head of the screw was flush with the superior aspect of the clavicle. C, a double loop of No. 5 FiberWire
(Arthrex Inc, Naples, Fla) was loaded through both cannulated
screws. D, the clavicle was reduced, and the FiberWire was
tied to itself anterior to the coracoid.

The mean anterior, posterior, and superior translation


under a 70-N load for the intact specimens before WeaverDunn reconstruction was 9.82 4.51 mm, 7.39 4.16 mm,
and 5.63 2.14 mm, respectively. After ligament reconstruction, the Weaver-Dunn method demonstrated anterior,
posterior, and superior displacement of 13.10 6.02 mm,
11.17 4.60 mm, and 5.35 1.85 mm, respectively (Table 1).
There was statistically greater posterior translation after
the Weaver-Dunn procedure compared with the intact state:
P = .1142, .0315, .7136, for anterior, posterior, and superior,
respectively (Figure 8A).
The mean displacement after anatomical coracoclavicular
reconstruction was 7.24 3.24 mm, 6.41 3.67 mm, and
4.29 2.52 mm, respectively. There was no difference compared with the intact state: P = .9064, .0729, .1328, respectively (Figure 8B).
In the arthroscopic reconstruction group, the intact state had
mean anterior, posterior, and superior translation of 8.83
4.30 mm, 8.71 3.99 mm, and 4.38 2.45 mm, respectively.
The mean displacement after the arthroscopic coracoclavicular ligament reconstruction was 8.36 5.57 mm, 8.92 4.99
mm, and 4.01 2.16 mm, respectively (Table 1). There was no
difference in translation in any direction for the intact state
and after the arthroscopic reconstruction (Figure 8C).
The anatomical 2-bundle coracoclavicular ligament
reconstruction had significantly less anterior and posterior
translation than the Weaver-Dunn procedure (P < .05). The
arthroscopic method yielded significantly less anterior displacement than did the Weaver-Dunn procedure (P < .05).
There were no significant differences in load to failure
between the native ligament and tested reconstructions
(Table 1).

DISCUSSION
Surgical treatment of acromioclavicular joint injuries is typically reserved for complete dislocations. Although there
have been more than 60 described techniques to address this
problem, one of the most commonly used methods involves a
transfer of the coracoacromial ligament with either suture,
tape, or hardware supplemental fixation of the coracoclavicular ligament complex.20 Variations of this technique have
been used extensively in both acute and chronic dislocations.
In the acute dislocation, the surgical technique typically involves reduction with repair of the coracoclavicular

Vol. 34, No. 2, 2006

Anatomical Coracoclavicular Ligament Reconstruction

241

Figure 7. Summary of the testing sequence after each reconstruction.

ligaments and augmentation of this repair with absorbable


or nonabsorbable sutures, prosthetic tapes, screws, and
other types of internal fixation. The premise of these techniques is that the coracoclavicular ligaments will heal and
will biomechanically withstand forces equivalent to or
near its prerupture tensile strength.
In chronic dislocations, reconstruction of the coracoclavicular ligaments has been advocated.5,12,20,23,25,26 One of
the most popular methods embraced is the transfer of the
coracoacromial ligament and resection of the distal clavicle.
However, biomechanical properties of the coracoclavicular
ligament transfer and the strength of this tissue have come
into question.12,13,17 In 2 recent biomechanical evaluations of
acromioclavicular joint dislocations, the coracoacromial ligament transfer was found to have approximately one fourth

of the initial fixation strength of normal coracoclavicular


ligaments and less than one half of the appropriate stiffness
to restore stability to the intact joint before healing. This
finding has been substantiated by clinical data reporting
recurrent subluxation or even dislocation occurring in the
chronic setting as high as 30%.25,26 This finding has led many
surgeons to recommend augmentation of the coracoacromial
ligament transfer with the use of absorbable or nonabsorbable
suture and various suture tapes. The use of a cerclage suture
or tape around the base of the coracoid and either around the
clavicle or placed through drill holes has also been evaluated
and supported in cadaveric studies.13,17,19 Furthermore, in an
attempt to provide a more durable reconstruction, several
surgeons have recommended reconstructing the coracoclavicular ligaments using free autogenous or allograft tissue.2,5

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Mazzocca et al

The American Journal of Sports Medicine

TABLE 1
Summary of the Mean Displacement and Load to Failure for the
Intact Specimens and After Each Reconstructiona
Type of Reconstruction
Condition

ACCR

Weaver-Dunn

Arthroscopic

Intact, mm
Anterior
Posterior
Superior

7.37 2.57
9.04 3.79
6.14 3.70

9.82 4.51
7.39 4.16
5.63 2.14

8.83 4.30
8.71 3.99
4.38 2.45

Reconstruction, mm
Anterior
Posterior
Superior

7.24 3.24b
6.41 3.67b
4.29 2.52

13.1 6.02
11.17 4.60c
5.35 1.85

8.36 5.57b
8.92 4.99
4.01 2.16

Cyclic displacement, mm
Superior

1.91 0.94

1.67 0.73

1.4 0.69

396.4 136.42

354.3 100.26

463.16 200.05

Load to failure, N
Superior
a

ACCR, anatomical coracoclavicular reconstruction.


P < .05 compared with Weaver-Dunn procedure.
c
P < .05 compared with intact ligament.
b

Intact vs Weaver-Dunn

displacement (mm)

25

* indicates P <.05

20
15

Intact
Weaver-Dunn

10
5
0
Anterior

Posterior

Superior

Intact vs ACCR

displacement (mm)

14
12
10
8

Intact
ACCR

6
4
2
0
Anterior

Posterior

Superior

Intact vs Arthroscopic

displacement (mm)

16
14
12
10
Intact
Arthroscopic

8
6
4
2
0
Anterior

Posterior

Superior

Figure 8. A, the mean displacement for the intact specimens


and after the modified Weaver-Dunn reconstruction. There
was statistically greater posterior translation after the WeaverDunn procedure compared with the intact state; P = .0315.
B, the mean displacement for the intact specimens and after
the anatomical coracoclavicular reconstruction (ACCR). There
was no difference in displacement compared with the intact
state. C, the mean displacement for the intact specimens and
after the arthroscopic coracoclavicular reconstruction. There
was no difference in translation in any direction for the intact
state and after the arthroscopic reconstruction.

Recent clinical reports have highlighted several of these


modifications of the Weaver-Dunn procedure. Weinstein
et al26 described a modified Weaver-Dunn technique in which
the coracoacromial ligament was transferred after a small
amount of the distal clavicle was excised, but the coracoclavicular ligaments were reinforced with 2 heavy No. 5 nonabsorbable sutures placed in a cerclage fashion through drill
holes in the clavicle and around the base of the coracoid.
They observed 96% good or excellent results in patients who
were treated with this technique within 3 months of their
injury. However, those patients treated after 3 months had
inferior results. Only 77% of those patients achieved good or
excellent results by their criteria. Of the 4 patients with
unsatisfactory results in the late repair group, 2 had complete loss of reduction contributing to residual symptoms.
In a report by Tienen et al,22 another modification of the
Weaver-Dunn procedure was evaluated. In the authors
description, the coracoacromial ligament was transferred
and reattached through drill holes in a more anatomical
position posteriorly, close to the insertion sites of the conoid
and trapezoid ligaments, rather than into the distal clavicle.
The distal clavicle and meniscus were removed, but a
braided 2-mm suture cord consisting of polydioxanone (PDS

Vol. 34, No. 2, 2006

Cordalcord, Ethicon, Johnson & Johnson, Amesford, the


Netherlands) was pulled through 2 drill holes in the lateral
clavicle, brought over the clavicle downward under the edge
of the acromion, and pulled superiorly and tied on the superior surface of the acromion. This procedure was an attempt
to stabilize the torn acromioclavicular ligaments. Of
21 patients, 18 had a good or excellent result; 3 patients had
residual subluxation and complete dislocation contributing
to a compromised result.
These 2 studies question the universal application of the
coracoacromial ligament transfer especially in chronic dislocations. It appears that to maintain reduction and to permit complete healing with improved stability and clinical
results, an anatomical reconstruction addressing not only
the contributions of the coracoclavicular ligaments but also
the injury to the acromioclavicular ligaments would appear
optimal. Surgical management to date has generally
focused on restoring superior stability of the distal clavicle
in reconstructing the coracoclavicular ligaments.
Most recently, the importance of the acromioclavicular
capsular ligaments in stability of the acromioclavicular
joint has been more clearly elucidated.9,10,15
Fukuda et al,10 in a classic study, reported the importance
of the acromioclavicular joint capsular ligaments to anterior
and posterior stability. They determined that the coracoclavicular ligaments, primarily the conoid ligament, contributed
a greater amount of constraint with larger displacement but
that the acromioclavicular joint capsule contributed constraint at small degrees of displacement. They concluded
that all the ligaments supporting the acromioclavicular joint
provide substantial contributions to stability. The importance of the capsular ligaments of the acromioclavicular joint
was further elucidated by Debski et al.9 The acromioclavicular joint capsule and ligaments, when transected, resulted in
significant increases in anterior and posterior translation. In
addition, the effect of transection of these ligaments resulted
in observation of significant forces in the coracoclavicular ligaments. In addition, they determined that these forces were
different for the conoid and trapezoid ligaments, respectively.
They concluded that suture or graft materials as well as the
intact coracoclavicular ligaments may be subjected to higher
forces and may be at risk for early failure in the absence
of supplemental fixation across the acromioclavicular joint.
These authors concluded that the intact coracoclavicular ligaments could not compensate for the loss of capsular function
during anterior and posterior loading as occurs in a typical
type II acromioclavicular joint separation. The reconstruction of only the coracoclavicular ligaments might not be
sufficient to prevent anterior-posterior translation at the
acromioclavicular joint, despite preventing superior translation. They theorized that residual anterior-posterior
instability after such procedures might contribute to persistent postoperative pain and inferior outcomes, especially in
patients who engage in overhead-throwing activities.
Klimkiewicz et al15 further demonstrated excessive posterior translation of the residual clavicle after distal clavicle resection, resulting in significant postoperative pain. In
their cadaveric work, they determined that the posteriorsuperior acromioclavicular capsular ligaments were critical in restraining excessive posterior translation.

Anatomical Coracoclavicular Ligament Reconstruction

243

Despite the common occurrence of acromioclavicular


joint separation and the extensive experience with surgery
in the treatment of these injuries, there is very little information in the literature regarding the biomechanical properties and performance of various augmentation and
reconstructive procedures.12,13,17,19 Motamedi et al19 evaluated the biomechanics of the coracoclavicular ligament
complex and augmentations used in repair and reconstruction. They evaluated augmentations performed with
braided polydioxanone or braided polyethylene sutures
placed through or around the clavicle. They also evaluated
a single 6.5-mm cancellous screw placed through the clavicle and into a single cortex of the coracoid. They found no
significant difference in the mean failure load between the
intact ligament complex and augmentations performed
with braided polydioxanone or braided polyethylene. In
addition, they found no difference in mean stiffness
between the intact coracoclavicular ligament complex and
braided polyethylene augmentations placed through drill
holes or around the clavicle. The single 6.5-mm cancellous
screw, however, had a significant lower failure load,
whereas the polydioxanone augmentations were significantly less stiff. Harris et al12 reported that bicortical
screw augmentation provided superior strength and comparable stiffness to that of the coracoclavicular ligaments.
Both of these studies did not involve cyclic loading and did
not evaluate anterior-posterior translation.
Lee et al17 performed a comparative biomechanical study
evaluating reconstruction of the coracoclavicular ligaments with free tendon grafts and comparing it with the
intact coracoclavicular ligament complex and a coracoacromial ligament transfer. Based on the weak initial fixation
and biomechanical performance of a coracoacromial
ligament transfer (20% of the intact state as reported by
Harris et al12) as well as the previously mentioned failure
rates and incomplete reduction noted after current operative
treatments, they evaluated and compared the coracoacromial ligament transfer, suture reconstructions performed
with No. 5 Mersilene sutures, 5-mm Mersilene tape placed
through a 4-mm drill hole, and semitendinosus, gracilis, and
long toe extensors placed through 4-mm drill holes in a
reconstructive fashion. They determined that the coracoacromial ligament transfer was the weakest construct. The use of
No. 5 Mersilene sutures and 5-mm Mersilene tape provided
better initial fixation strength. However, these materials do
not provide a lasting biologic solution, but they may have a
role as augmentation devices in acute dislocations, allowing
for healing of the native coracoclavicular ligaments. It is
important to note that in this study, a free gracilis, toe extensor, or semitendinosus graft had an ultimate failure load that
was equivalent to the native coracoclavicular ligaments.
Jari et al13 evaluated the biomechanical function of a
suture-type coracoclavicular sling procedure with a coracoacromial ligament transfer construct and a Rockwood screw
(DePuy Orthopaedics, Warsaw, Ind). The coracoclavicular
sling procedure was performed using 2 No. 5 nonabsorbable
polyethylene sutures looped around the coracoid process and
placed through a 1.5-mm drill hole. A 6.5-mm Rockwood
screw was placed through the coracoid in a bicortical fashion.
The coracoacromial ligament transfer procedure, in addition

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Mazzocca et al

to securing the transferred coracoacromial ligament through


drill holes in the distal clavicle, was also augmented with
a suture sling using 2 loops of suture passed through a
1.5-mm drill hole and around the coracoid process. This
study was unique in the assessment of not only superior
translation but also anterior and posterior translation after
these surgical procedures. Furthermore, in situ graft forces
were measured of all surgical constructs. This study also
evaluated the coracoacromial ligament transfer with
suture augmentation, attempting to address the biomechanical properties of a coracoacromial ligament transfer
with augmentation. With the coracoclavicular suture sling
procedure, anterior and posterior translation significantly
increased by 110% and 330%, respectively, in response to
these loads. Anterior-posterior and superior translation for
the coracoacromial ligament transfer construct was significantly increased by 110%, 360%, and 100%, respectively.13
Of importance, the in situ forces for all 3 surgical constructs
were significantly increased compared with the intact coracoclavicular ligaments in response to anterior and posterior
loads. The authors concluded that current surgical procedures do not have the appropriate stiffness to restore the
stability of the intact joint before healing. These authors
demonstrated a possible biomechanical explanation for the
observed recurrence of subluxation and dislocation after
coracoclavicular ligament reconstruction. These findings
further underscore the contribution of the acromioclavicular
joint capsular ligaments to restraining anterior and posterior translation. They suggested that reconstructive procedures that preserve the articulating surfaces and maintain
lower joint contact forces may be preferable to those in
which articulating surfaces are compromised. In the surgical treatment of chronic acromioclavicular joint dislocations,
the distal clavicle is commonly resected, and the acromioclavicular capsular ligaments are therefore compromised.
The Rockwood screw actually decreased posterior translation compared with the intact coracoclavicular ligaments
and provided highly rigid fixation, which may explain some
of the complications seen in clinical practice.
Several conclusions can be made from a review of these
more recent biomechanical studies: (1) the well-accepted
coracoacromial ligament transfer is only one fourth as strong
as the intact coracoclavicular ligaments; (2) strength can be
improved by augmenting the coracoacromial ligament transfer with a suture or tape material in a sling fashion around
the base of the coracoid process; (3) the coracoacromial ligament transfer with augmentation has been shown to have no
effect on anterior-posterior translation of the distal clavicle;
(4) surgical reconstructions have much higher in situ graft
forces when the acromioclavicular joint capsule is either
injured or incompetent; and (5) a free tendon graft provides
a substantial improvement in initial stability or load to failure equivalent to the intact coracoclavicular ligaments and
represents a biomechanical improvement compared with
coracoacromial ligament transfer.
It would appear from a review of this available literature
that maximum clinical outcomes after surgical treatment
for chronic acromioclavicular joint dislocations should focus
not only on controlling superior translation of the distal
clavicle but on also addressing anterior and posterior

The American Journal of Sports Medicine

stability at the acromioclavicular joint level. Re-creation


of the anatomical orientation of the conoid and trapezoid
ligaments with a technique that also controls excessive
anterior and posterior translation could potentially achieve
this goal.
With this in mind, it was our intent to improve the surgical technique for the symptomatic chronic dislocation. As
in any other ligament reconstructive procedure, improved
biomechanical function and clinical outcomes would be
predicated on the use of a graft of sufficient strength, accurate and anatomical placement, reproduction of pertinent
anatomy, strong fixation, and ultimately, biologic healing. It
was also our intent to validate the surgical technique with
a biomechanical evaluation that included not only superior
displacement but assessment of anterior and posterior displacement of the distal clavicle. We also believed it to be
clinically more applicable to evaluate our reconstruction
with cyclic loading, thus entering the possibility of an earlier range of motion postoperative rehabilitation program.
Our study demonstrated that an anatomical coracoclavicular ligament reconstruction repairing the conoid and
trapezoid ligaments with a double-bundle 2-tunnel technique controlled superior displacement and, in addition,
anterior and posterior translation. This reconstruction
closely mimicked the intact state for all 3 directions.
The anatomical coracoclavicular ligament reconstruction had significantly less anterior and posterior translation than did the Weaver-Dunn procedure. This control
of anterior and posterior translation occurred despite no
attempt to specifically reconstruct the acromioclavicular
capsular ligaments. This result suggests that this reconstructive technique was stiffer and perhaps overconstrained. The arthroscopic coracoclavicular ligament sling
method also yielded significantly less anterior displacement than did the Weaver-Dunn procedure. These findings
are consistent with the findings of Jari et al13 when a bicortical screw was placed from the clavicle into the coracoid.
In the study by Jari et al,13 the only surgical reconstructive
method that controlled anterior-posterior and superior
translation was the bicortical screw fixation method. Use
of a coracoclavicular fixation with a screw requires a second
procedure for removal and, in the acute dislocation, requires
or assumes that adequate healing of the ruptured coracoclavicular ligaments will occur. Certainly, in a chronic acromioclavicular joint dislocation, some form of graft tissue will be
required to reconstitute and reconstruct the coracoclavicular
ligaments.
Another possible explanation for our finding of no increase
in anterior-posterior translation in the anatomical coracoclavicular reconstruction and arthroscopic reconstruction
groups is that the conoid and trapezoid ligaments do control
anterior and posterior translation when the acromioclavicular ligaments are sectioned.9,10 An anatomical reconstruction
reproducing both the trapezoid and conoid ligaments would
then be expected to control anterior-posterior translation.
It is interesting that in our study there was no statistical difference in superior displacement with cyclic loading
among the groups. The anatomical coracoclavicular ligament reconstruction using free tendon graft, the arthroscopic coracoclavicular ligament suture or sling method,

Vol. 34, No. 2, 2006

and the modified Weaver-Dunn procedure controlled


superior displacement equally. It should be remembered
that the modified Weaver-Dunn procedure and the arthroscopic coracoclavicular reconstruction used in this study
were augmented repairs using a strong No.2 suture. This
finding is in contrast to that of Jari et al,13 who reported
increased superior translation with a coracoacromial ligament transfer compared with the intact specimen. In the
coracoclavicular ligament suture sling method they evaluated, there was no significant superior displacement compared to the intact specimen, again suggesting that this
particular method may be effective as an augmentation
but, as mentioned previously, in the chronic state with poor
tissue and if a suitable tendon graft material is not provided, these suture materials will ultimately fail.13
Although the Weaver-Dunn procedure had higher anterior
and posterior displacement compared with the intact state,
this result did not achieve statistical significance. This
finding is in contrast to that of the study by Jari et al,13 which
demonstrated significantly greater anterior and posterior
displacement of a coracoacromial ligament transfer compared to the intact acromioclavicular joint. We cannot
explain the difference in our results compared with those
by Jari et al,13 which could be secondary to differences in
surgical technique employed in the study, differences in
testing conditions, and differences in suture used. Perhaps,
surprisingly, the arthroscopic coracoclavicular ligament
reconstruction originally described by Wolf and Pennington27
controlled anterior, superior, and posterior translation
similar to the intact state.
The use of 2 No. 5 FiberWire sutures used to stabilize the
coracoclavicular complex was stiff and may represent the
suture equivalent of a bicortical coracoclavicular screw. We
would be concerned of the lack of supplemental autograft or
allograft tissue that could subsequently revascularize and
reconstitute as a coracoclavicular ligament complex. In the
absence of suitable graft material, this technique could ultimately lead to clinical failure as the suture material fails. In
testing the load to failure, we also found no statistically significant differences between the 3 procedures compared with
the native ligament. This finding is consistent with that of
Motamedi.19 He found no statistically significant difference
in load to failure with either of the coracoacromial ligament
transfer techniques that utilized either braided polydioxanone or braided polyethylene suture placed through or
around the distal clavicle. This finding is in contradistinction
to that reported by Lee et al17 that showed the native ligaments fail at a much higher load than do a coracoacromial
ligament transfer. However, in the study by Lee et al,17 the
coracoacromial ligament transfer was not augmented. In
addition, they demonstrated that suture repairs performed
with No. 5 Mersilene suture or 5-mm Mersilene tape also
failed at much lower values than did the native ligament.
Once again, this finding is in contrast to the finding of our
study and may be reflective of a different suture material as
well as variance in surgical technique.
The strengths of this study include bone density measurements; cyclic displacement in anterior, posterior, and superior directions; and an ultimate load to failure of 3 reported
techniques. The weaknesses include that this is a cadaveric

Anatomical Coracoclavicular Ligament Reconstruction

245

study and that the test conditions used in this study may not
closely replicate the in situ conditions in patients.
In conclusion, we believe the coracoclavicular ligament
reconstruction described has the potential to be an improvement in the surgical armamentarium of treating acromioclavicular joint dislocations, especially in the chronic setting.
It is our opinion that this reconstructive technique adheres
to the principles of ligament reconstruction that have been
proven in other anatomical regions during the years. The
principles of using a graft of sufficient strength with potential for revascularization, paying attention to anatomical
detail replicating ligament anatomy, and supplementing the
graft with strong initial fixation to minimize recurrent
displacement are satisfied with the proposed technique.
We have demonstrated in our laboratory study that this
reconstruction can control superior displacement under
cyclic-loading conditions and approximate the anterior and
posterior displacement values observed in the intact specimen. These advantages may eliminate recurrent subluxation
and dislocation and lower the incidence of postoperative pain
secondary to residual anterior-posterior instability with compromised clinical outcomes that have been observed with the
traditional or modified Weaver-Dunn procedure. The clinical
effectiveness of this double-bundle anatomical reconstruction is the subject of an ongoing clinical project.

ACKNOWLEDGMENT
The authors acknowledge the generous support of this
research study by the Arthrex Company (Arthrex Inc,
Naples, Fla).
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